Book Reviews

MALI By Andrea L. Stamm, Dawn E. Bastian, and Robert A. Myers, Oxford and Santa Barbara: Clio Press, 1998, 327 pp., $69.00 (hardcover). MALI 2000. COUNTRY REVIEW By Robert C. Kelly, Houston: Country Watch, 2000, 84 pp., $39.95 (spiral-bound softcover). WAITING FOR RAIN: LIFE AND DEVELOPMENT IN MALI, WEST AFRICA By Lewis W. Lucke, Hanover, Massachusetts: The Christopher Publishing House, 1998, 197 pp., $16.95 (softcover). INNOVATION AND INDIVIDUALITY IN AFRICAN DEVELOPMENT. CHANGING PRODUCTION STRATEGIES IN RURAL MALI. By Dolores Koenig, Tiéman Diarra, Moussa Sow et al. Ann Arbor: The University of Michigan Press, 1998, 279 pp., $49.50 (hardcover).


402
Critical Analysis. The author, in his dedicatory Letter to the Chief Secretary to the Lord Lieutenant of Ireland, shows that he has extended his views to a subject that is too much neglected by the generality of physicians,?the relations of medicine with the policy of nations; and he also proves that he well understands the subject as far as it is connected with the matters treated of in tins work, if a coincidence of his views with those of the most esteemed politicians may be considered a proof of such knowledge. He opposes the notions of those (we cannot call them disciples ot Malthus, they have so much mistaken his doctrines), who think that the art of medicine is useless on such occasions as those contemplated in this work; that is to say, when contagious fever is ravaging a country oppressed by famine and a tooabundant population ; and who believe that physicians can do nothing better than look quietly on, and behold fever " doing its businessand he, with much energy and judgment, exposes the folly of their arguments. There is one important circumstance which, however, he has not noticed, apparently because he could not enter into sufficient details on this occasion, that refutes the policy of those who have misunderstood, in the way just mentioned, the doctrine of Malthus: it is this ; that, even conceding to those politicians (which we are very ready to do) the point, that the population of a country must be confined within a certain proportion to the extent of the means of subsistence, (food,) the art of medicine, although it cannot directly increase the number of people,* can do what is more advantageous to the welfare of nations,?it can maintain an older and a more effective population than that which would exist without the aid of the art of medicine. For, when the population of a country is thinned by an epidemic or pestilential disease, the mortality falls in at least an equal degree, and commonly in a greater ratio, on persons of the middle period of life; thus temporarily destroying, to a certain extent, a nation's chief strength, and giving origin, for several years afterwards, to an increase of the ordinary proportion of births, and thus filling the country with comparatively useless individuals. Although medicine cannot increase the population of a coun-* A man on dying, in a country where the means of subsistence are limited, and not beyond the wants of the existing population, always gives place to another, who, but tor this circumstance, would not have been born, or who would die ot want. The number of marriages, in regard to the population of a countrv> always increases considerably after extraordinary mortality, and the subsequent ratio of the births to the deaths is also greatly augmented; as Short long since observed, though he gave an erroneous explanation of the circumstance. The pestilence which ravaged the north of Prussia at the beginning of the present century, and winch, according to Scssmii.ch, (Gotlliche Ordnung, u. w. s p. 52?,) carried off one-third of the population, was immediately followed by such an augmentation of the proportion of births, that the ratio to the deaths was as 3^0. to 100; whilst the ordinary ratio is only as about 120 to 100.
Dr. Harty on the Contagious Fever epidemic in Ireland. 403 try,* it can preserve alive, to a certain extent, that which exists: it may, and undoubtedly does, thus prevent the births of many children.t But this is an. advantage, if the principles of Malthus are true; for, as M. Say remarks,% "chaque homme adulte etant un capitale accumule qui represents toutes les avances faites pour le mettre au point oil il est," it must be admitted that this capital, which is composed of annual appropriations, augments or decreases in proportion as the individual lives beyond, or approaches to, the epoch of his birth. So that (excepting the value of the labour and industry which the pregnant woman would have evinced but for her pregnancy and puerperal confinement, and the expenses attendant on this condition), the loss of a new-born child is of but little importance; whilst that of an adult destroys all the capital accumulated in him, and the interest this capital would have produced.
The island Juan Fernandez, at the tune wnen it was uncovered by modern Europeans, presented a scene of the greatest solitude in regard to animal beings, although it abounded ivith the most agreeable and luxurious vegetation. The navigator who then first stepped on its shores left behind him a male and female, deer, which gave origin to so numerous a progeny, that, in a few years, the pasturage of the most fertile ?f its valleys was devastated, and furnished but an insufficient supply of aliment for its inhabitants. All the horrors ol want ivere then experienced ; the weakest animals were deprived of * Even vuccinatinn lias riot been found qualified to increase, to any considerable extent, the population of a country. Watt, by an examination of the ?Kills of Mortality for Glasgow from 1783 to 1813, has shown that the ratio of the mortality of children below two years of age has been equally great before and after the use of vaccination; the greater proportion being preserved from the fatal effects of small-pox only to die of some other disease. This fact is not peculiar to Glasgow : the same lias been observed in other parts; in Pavia, for in-*ianee, wiiere every ciniu is vaccinaieu, mc mun..?.v -little lessened within the city, but it was increased in the suburbs : a circumstance also remarked by Watt at Glasgow. But, admitting, as is probably the case, if the whole of' any of the nations of Europe be considered, and as it seems to be Proved in France by Duvillard, that the practice of vaccination does pie-?^rve a small proportion of individuals to the adult a^e, it is not shown that it increases the population, as will be presently shown; but then it does, what ive ar?ue the art of medicine in general does, it produces an older and more ? lma t'nnml that, in France, the medium-pelrioiroV'nfe"irefore 'vac^nagon-as ve^^cco^nl"^^ ihe staTenIcnt?of OmER?thil period SV8,M1 in tlie "l "?e seventeenth ; and 32,295, in the iniauiei?-^ the ca[cu|a.
creased, he says, by vaccination, which makes it 1p J tions^of Watt and Iliisconi are applicable to aU we^ ^ tfae p0Dnlati011 has gra. dually lessened since the year 1620, just in the proportion in which the ratio o deaths amongst the population iias lessened. disease came to augment the ravages of famine, and a great proportion of the deer perished to re-establish the due propotion to the diminished supply of the means of subsistence.
The decrease in the number of the inhabitants permitted a considerable proportion of tlie island again to become covered with luxurious vegetation, and the deer again experienced no other obstacles to their multiplication than the limits of their natural fecundity. At this time, a dog and a bitch were set on-shore in this island, and soon produced a sufficiently numerous posterity to wage a terrible war with the first inhabitants.
The race of the Jatter diminished rapidly ; the strongest and most active retired to concealed places, whence they descended from time to time only as famine called them forth. In these sallies, the weakest and most imprudent deer became the prey of the dogs, but still it was only the more strong and active of the dogs that could carry them off; so that a new equilibrium became established amongst the two species of inhabitants: the weakest of the deer became the prey of the dogs, whilst the strongest of the latter were alone able to obtain the means of subsistence.
Dr. Harty on the Contagious Fever epidemic in Ireland. 407 tion, et rien ne peut la diminuer, au moins tl'une maniere permauente, que cc qui attaque les sources cle la production." It has too, unfortunately, been found, that a temporary increase of the means of subsistence, is itself the means of producing famine and pestilence. A very abundant production of corn and other products of agriculture causes these articles to become so cheap,* that the cultivation of them ceases to be profitable for a few ensuing years; agriculture is consequently neglected, and scarcity is soon the necessary result: and, if in this state of matters this scarcity comes to be increased by au unfavourable season, every preparation is made for the ravages of pestilential disease. Even plenty itself appears to be more immediately productive of starvation, in certain states of a nation ; of which Ireland seems to have furnished an example in the year 1815, as Dr. Grattan has shown, in his Medical lieport, (pages 14 and 22.) The harvests of 1814 and 1815, Dr. Grattan observes, proved more abundant than had ever been remembered ; but the sudden transition from a state of longprotracted war to that of peace so deranged the pursuits, and gave such a check to the affairs, not only of the mercantile and manufacturing classes, but also of the landed proprietors, and of the agricultural interests, that the greatest distress followed.
Manufactures languished, trade decayed, all enterprize had ceased, and, without employment, the great mass of the poorer portion of the population were starving in the midst of plenty. Fever then began to prevail to a great extent amongst them.
We should apologize to our readers for having given so very imperfect a sketch of the matters appertaining to this highly important subject: it was hardly right, inaeed, to enter into the consideration of it at all on this occasion, as much space would be requisite for a perspicuous development of it. We return to the work of Dr. Harty ; for, although we cannot produce an analysis of its contents, we may give a catalogue and a character of the principal parts of them. The volume commences with " preliminary observationsthe objects of which are to state the nature of the contents of the book, and the author's views in their production ; to explain the way in which it has been constructed, and the sources of the documents it comprises; and to express particularly the author's obligations to Drs. Barry of Cork, Carroll of Limerick, Bracken of Waterford5 Williamson of Cai i ick-on-Sun, Mawe of Tralee, Ryan of Kilkenny, and M'Donnel, Stephenson, and Thomson, of Belfast, for their very important contributions. * And this cheapness increases the number of ma)rinses, (it has, at least, been cleaily shown to be the case in Sweden by Wargentin,) and thus leads to a redundant population, which augments the evils which soon lesult honi it, as designated in the text.

4OS
Critical Analysis, The author then gives an <c historic sketch of the commencement, progress, and duration, of the epidemic in the four provinces of Ireland." He next shows the 11 extent and mortality of the epidemic and then produces some " introductory observations to the history of the epidemic in Dublin and Cork}" describes the " progress and management of the epidemic in Dublin enters into a " review of the epidemic in Cork, and of the legislative measures adopted for the suppression of fever;" compares the epidemics of 1741 and 1817; and concludes the first part of the work with a general " review of the causes, medical and statistical, productive of epidemic fever in Ireland." 'An Appendix (occupying nearly three hundred pages) to this, consists of the documents from which the observations and inferences above alluded to were derived.
In the historic sketch of the causes, &c. of the fever, the author shows, that, for a century at least, Ireland has been afflicted with this disease to such an extent as to substantiate the statement of some of our oldest medical authorities, that fever is one of the u endemical or reigning diseases" of the island.
Dr. Gerard Boate, in his Natural History of Ireland, published in Hi52, enumerates, amongst the diseases to which that country is " peculiarly obnoxious," " a certain sort of malignant feavers, vulgarly called Irish agues, because they are at all times so common in Ireland." But the ordinary extent of this malady has fallen far short of the epidemics of 1741, 1801, and 1817, in regard to the extent of their prevalence over the island, and the mortality which has thence resulted. This section of the work, as well as the following respecting the extent and mortality of the epidemic in 1817, are merely statistical ; but the two following sections, on the progress and management of the fever in Dublin and Cork, presents the author with an opportunity for showing the great comprehensiveness of his views, and the solidity of his judgment, as a philosophical and practical physician ; and it is this part of the work, and his " general review," &c. that have drawn forth the attempt we made at the commencement of this article to express the sense we have of his merits. We have been particularly pleased with the spirit with which he exposes the evils which resulted from the bad measures of medical police that were adopted in the early stages of the epidemy, in consequence of the conflicting opinions of the ministers of the government and the physicians; and we have derived no less gratification from the consideration of his own views of the proper policy on such occasions as those alluded to in this work.
The author considers the causes of the prevalence of an epidemic fever under the distinctions of secondary and primary, which, he thinks, might with propriety be designated medical % Dr. Harty on the Co?itagious Fever epidemic in Ireland. 409 and statistical. " The secondary or medical causes," lie says, "such as contagion; crowded, filthy, ill-ventilated, apartments; neglect of personal cleanliness; are those which more immediately lead to the formation of fever: the primary or statistical, are those which give origin to the causes just mentioned, by establishing the peculiar condition and habits of a people. The former are the causes which generate fever in every country ; the latter are those which distinguish one country from another, and which render the disease more or Jess extensively prevalent therein according to their strength and activity." These matters are discussed at length by the author in a particular manner, and in reference to the opinions which have been advanced respecting them by others. His own conclusions are indicated ill the passage just transcribed ; but we may nevertheless state in plainer terms, that he believes that fever of endemic origin may become contagious in its progress, when the secondary causes enumerated in the paragraph just alluded to exist to a certain extent; and he believes that such has been the case with respect to the late epidemy of Ireland. These doctrines he establishes, we think, in a tolerably satisfactory manner; or, to speak with more strict propriety in respect to the existing evidence, he has shown that such inferences are the most probable inferences that have hitherto been made, and, consequently, are those which should direct the policy of nations on occasions similar to that of the existence of the epidemy under consideration. At present, we have more negative than positive knowledge of the nature of the contagious matter producing such a disease as that just mentioned ; and it cannot therefore be said, that the opinions of those who profess the doctrine of exclusive contagion in regard to the origin of the'malady, are positively refuted.
In order that the opinions we have expressed respecting this Work may not lead some of our readers to purchase it, to whom it will be almost devoid of utility, we should state that it contains but little that relates in a direct manner to either the practice of medicine or the pathology of fever. It is as a treatise on a subject of medtccit police that it must be characterized ; and to those who are disposed to the study of this subject, by duty or inclination, we think we cannot recommend it too earnestly. This work, we have just discovered, escaped the attention of our predecessor in the management of this Journal ; but, though so long a period has elapsed since the time of its publication, we could not willingly suffer to pass unnoticed such a discussion on so important a point in the practice of surgery, even were Ave not induced, by a sense of justice towards the author, to lay before our readers the proofs he here adduces of the propriety of the opinions he had previously advanced ou this subject, and which were stated in this Journal on a former occasion. (Vol. xxxviii. p. 02.) Some late respectable writers, we are aware, have spoken of the question considered in this work, as one that has long been decided ; and one of them says, " For my part, I have not known any difference of opinion on the point: in books, it is true, it has been most amply discussed before the present generation were in existence; but, in British practice, all doubts have long been at an end." That such is not the case, is shown by the documents brought forward in the tract before us ; and, whilst there are men of some place and authority who write in favour of, and medical officers who pursue, the practice here reprobated, we cannot but regard with deep interest, because of the influence they must exert, the arguments adduced against it by a surgeon of such professional rank and talents as the author of this work.
On the return to England of the squadron which had been engaged in the battle of Algiers, the author says, 411 my letter. These documents so fully illustrate and corroborate the truth of the doctrines which I previously endeavoured to inculcate, that I hasten to lay them before the profession, in the hope of settling definitively a question so long agitated, so interesting to humanity, and of such vital consequence to the national service in future wars. " As some of these official documents," the author adds, " are very extended, and would occupy much space, I trust I shall be excused by the writers in giving such parts only as appear to bear more directly on the subject under consideration ; and I shall endeavour to give such extracts with all due candour and fairness, stating the opinions of those gentlemen who oppose or confirm the point in controversy." The abstract here alluded to is preceded by some general remarks on the evidence comprised in those official communications; and, from the concise manner in which they are stated, it becomes necessary for us to transcribe them in detail. " Those surgeons who may appear to have been less successful in (he general result of their operations than others who pursued a different plan, and were actuated by other sentiments, cannot in justice reflect ?n themselves, however much it may be lamented, particularly in the sea-service, as their mode of proceeding was influenced by the opinions of gentlemen of high professional talents, and of acknowledged experience in practical surgery. The principal object of this enquiry is, to point out the dangerous tendency of those opinions, which appear to be founded on plausible reasonings deduced Irom effects theoretically supposed to occur, rather than the result of actual experience or just observation. Utrn and three thigh cases, a!l of which recovered. It will be seen, and is truly worthy of remarking, that one of these patients, far from suffering any shock or alarm, on having his leg completely carried off by a cannon-shot, very coolly and deliberately removed the handkerchief from off his neck, and wrapped it round the mangled stump, to stop the effusion of blood till he could reach the surgeon. " The surgeons of two or three of the ships speak of the danger that sometimes occurs from the sudden loss of a quantity of blood, on being severely wounded in battle, particularly the surgeon of the Superb; but, in these cases even, the patients are stated to have been perfectly collected, and free from every thing like sensorial affection, it is here also proper to remark, that the above circumstance is observed upon in my publication already alluded to, (page 9.) The general effect of a sudden abstraction of blood from the system, is feebleness of pulse, pallid countenance, faintness, and even syncope; but all these apparently alarming symptoms are speedily removed by administering some generous cordial, as wine, diluted brandy, &c. To these occurrences "We cannot justly apply the doctrine of shock and alarm to the constitution ; and, in fact, need not retard the operation beyond the period necessary to rouse the dormant powers of the system by the means already pointed out, and which, at most, require not many minutes to effect.
"The greater number of wounds inflicted by contending armies, are those arising from grape-shot and musket-balls; whereas, in naval engagements, the very reverse of this is the fact in an increased ratio ; for the wounds received in ships-of-war are generally produced either by the direct stroke of a cannon-shot of large dimensions, or, what is still more lamentable, by ragged fragments of timber violently rent from the planks or beams of the ship, impelled by balls infinitely larger than any ever employed in fields of battle. Wounds inflicted by splinters of wood are always more extensive, accompanied with frightful contusions and lacerations of the soft parts. " If, then, there be any shock or alarm to the constitution, occasioned by gun-shot wounds, which should deter or interdict the armysurgeon from performing immediate amputation when such an operation is deemed indispensably necessary, how much more alarming must we expect to find this mental shock among the wounded men in naval battles, whose injuries are found much more serious ano formidable, as Wo have fully shown in the preceding paragraph, iiut the truth is, that, until a late writer talked of shock and alarm, unfortunately, in all cases of gun-shot wounds, and stated the danger of amputating before the constitution had recovered from these gratuitous and hypothetical affections, no such idea had ever entered the minds of our most experienced naval surgeons. 41 {< Critical Analysis. But what man, Jet me ask, can bear the severe pressure of a tiglifc ligature like the tourniquet on a wounded liinb for four or six hours7 ?without an effort to relievo himself from the painful stricture occasioned by the instrument, however short that period might be ? The probability and danger of such an occurrence may, with propriety, be urged as a strong argument in favour of immediate amputation, which would effectually guard against such fatal accidents. It is indeed scarcely possible to suppose that a ligature could be continued for such a length of time, even on .1 perfectly sound limb, by which the circulation is impeded or totally obstructed, without being attended with serious consequences, and even a risk of ultimate gangrene; not to mention the extreme suffering of the patient. " Since, in my recently published Observations in Surgery, I have entered pretty largely on the nature of the irritation consequent on gun-shot wounds, in which I endeavoured to demonstrate that it is not an immediate result, but an increasing affection in a greater or less degree, proportionally to the extent of the injury and the nature.of the parts wounded, I do not feel it necessary to say more here, excepting briefly to observe on gun-shot fractures of the extremities requiring amputation. Let us suppose, in wounds attended by such circumstances, the bones much shattered, and the patient left for a few hours before the operation is had recourse to ; surely we arc not to conclude that the unhappy patient, during this painful suspense, can remain in a tranquil or quiescent state: certainly not: the probability is, that the muscles of the injured member will be attacked with spasms; the limb more or less thrown into involuntary action ; and the nerves, heretofore untouched, lacerated or grated upon by ragged points, detached fragments, and sharp edges of the fractured bones, thereby increasing the irritation in an infinite degree. " In addition to the documents before 11s, illustrative of the fatal consequences generally attending deferred amputations in battle, I am authorized to state, by ocular witnesses, that, in two of the ships where this doctrine was fully acted upon, several officers and seamen, so wounded as to require immediate amputation, died in the cockpit before the period had elapsed in which the surgeon felt himself justified or warranted to commence operating: two cases in particular, one of which was badly wounded a little above the knee, and the other at the ankle ; and it is necessary to remark, that ail the amputations performed in that ship were arm-cases." We s'uill select from the documents above alluded to some other of the most important of the facts they designate, in addition to those above stated by the author,, in order that our view may embrace some of the more particular points of the evidence; and if, as a matter of form, we are to state our opinion respecting the inferences drawn from them by the author, we must acknowledge them to be apparently correct, and characterized by the most dignified liberality.
The first report is that of the surgeon of the Impregnable, in which vessel amputation was performed in eleven cases. (July 415 two patients finally recovered. In three instances, however, the operation was not performed until some daj7s after the injury, so that these are cases not expressly relative to the question in dispute. In the rest it was practised generally about four or five hours after the injury.* In two instances the patients died immediately, and in three about an hour, after the operation. The inferences from these cases against delay of the operation, are not, perhaps, of the most forcible kind ; as, it is said, some of the patients had been sick just previous to the action ; others were burned by explosions ; and, besides these circumstances, the thermometer in the c ockpit, after the explosions, and consequent presence of seventy burned men and hoys, stood as high as from 136? to 140?. Willing to make every allowance tending to favour the reporter, we have supposed that the last circumstance was peculiar to this vessel; though it is highly probable that it was not.
Amputation was performed in tive instances on-ooara tne Granicus: four recovered. They were all arm-cases. Only one patient died, forty-two hours after amputation, and he had sustained great loss of blood previous to his removal to the cockpit." Amputation was effected about five or six hours after the injuries, speaking generally,